Provider Demographics
NPI:1285727693
Name:WITTLES, JOEL MERRELL (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:MERRELL
Last Name:WITTLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-9596
Practice Address - Country:US
Practice Address - Phone:317-274-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48314174400000X
IN01062891A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200842780Medicaid
CAA51003Medicare UPIN
IN200842780Medicaid
CA00G483140Medicare ID - Type UnspecifiedMEDICARE NUMBER